Factors orthopaedic surgeons should consider when prescribing opioids

Orthopaedic surgeons are the third-highest physician prescribers of opioids, writing more than 6 million prescriptions a year. Because over-dispensing of opioids is a factor contributing to the ongoing opioid epidemic, researchers at Johns Hopkins surveyed orthopaedic providers to better understand what drives their prescribing practices and to identify gaps in knowledge and potentially worrisome trends. In their survey of 127 orthopaedic providers in the Baltimore area, the Johns Hopkins researchers found that respondents frequently recommended prescribing a nine-day supply of around-the-clock oxycodone doses following commonly performed orthopaedic surgeries. The researchers also found that risk factors that might normally warrant prescribing fewer opioids, such as a history of drug misuse or depression, often did not diminish hypothetical prescribing rates.

The researchers published their findings on June 22 in the Journal of Opioid Management.

In the survey, researchers gauged responses to six scenarios routinely encountered by orthopaedic surgeons. They found that although increased experience was associated with decreased prescribing, 95% of respondents recommended prescribing at least 55 oxycodone pills following five of the six surgeries described. That amounts to a nine-day supply of medication, more than current recommendations from the Centers for Disease Control (issued since the survey was conducted) that no more than a three- to seven-day supply routinely be prescribed. In addition, comparing this result with recent studies looking at opioid use after orthopaedic surgery suggests that this number of doses was more than what is usually required to adequately treat post-operative pain.

The study also found that 62% of respondents reported that they do not routinely use their state-sponsored electronic prescription drug-monitoring program, which can help flag when patients go "doctor shopping" for a new source of pills. Finally, 79% of respondents reported that they do not provide opioid disposal instructions to their patients, which researchers are concerned can lead to unused pills remaining in homes and potentially getting into the wrong hands.

"Our findings show that there are clear knowledge gaps among orthopaedic surgeons for best practices for prescribing opioids that can and should be addressed," says lead author Constance Monitto, M.D., assistant professor of anesthesiology and critical care medicine and director of the pediatric acute pain service. "Evidence-based guidelines for opioid prescribing for specific procedures are also needed to curb overprescribing while still adequately treating pain."

Monitto notes that since the time the study was performed, Johns Hopkins has created a committee to help establish prescribing guidelines specifically for routine surgical procedures, and an additional group is developing educational materials for patients on safe handling and disposal of medications. She says other hospitals and health care centers should follow suit in order to curb overprescribing and decrease the risk of patient harm.

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